GIT ‘N SPLIT EMPLOYMENT APPLICATION

FOR STORE PERSONNEL: Store Use Only

Store # ______

____ Store Manager Beg. Day____/____/____

____ Assistant Manager Starting Wage ___________

____ Sales Associate Position _________________

We consider applicants for all positions without regard to race, color,

religion, sex, national origin, age, disability, or any other legally protected status.

Referral Source: ____Advertisement ____ Friend ____ Walk-in ____ Other ___________________

PERSONAL INFORMATION
Name (Last, First, Middle)										Today’s Date ____/____ /____
Present Address (No., Street, City, State, Zip Code)									Telephone Numbers ( ) _____-_______ ( ) _____-_______
Have you ever worked for Gas ‘N Shop or Git ‘N Split? ____Yes ____ No		If yes, when & where?			Are you at least 18 years of age? ____Yes ____ No Are you at least 21 years of age? ____Yes ____ No
Have you ever been convicted of a crime other than a routine traffic violation? (A conviction is not necessarily a bar to employment.) ___ Yes ___ No If yes, please explain:
Only US citizens or aliens who have a legal right to work and remain permanently in the US are eligible for employment. Are you authorized to work in the United States on an unrestricted basis? ____ Yes ____ No
Based on the job description presented to you, are you able, with reasonable accommodation, to perform all of the essential duties of the job for which you are applying? ____ Yes ____ No If the answer is no, please describe below which duties you are unable to perform. Applicants will not necessarily be disqualified if they are unable to perform a particular job duty (or duties).
Position for which you are applying		Pay Rate Expected _______per________		Date Available to Work _____/_____/_____			_____Full-time _____ Part-time			_____ Permanent _____ Temporary
With regard to store assignments, do you have any location preferences or restrictions? ____ Yes ____ No If yes, please specify below.
Are there any hours, shifts, or days you cannot or will not work? ____ Yes ____ No If yes, explain below. Please mark 1, 2, & 3 for your first, second, and third shift preference. ____6 a.m. to 2 p.m. ____2 p.m. to 10 p.m. ____10 p.m. to 7 a.m.
Certain jobs within the company require use of a car or other motorized vehicle. If the use of such a vehicle were required in the job for which you are applying... Do you have or can you get a valid drivers license? ____ Yes ____ No Do you have access to a car or other motorized vehicle? ____ Yes ____ No Do you have or can you get liability insurance on such a vehicle? ____ Yes ____ No
EDUCATION
School	Name and Location		Course of Study			Last Year Completed		Did You Graduate		Diploma/ Degree
High						1 2 3 4
College						1 2 3 4
Other						1 2 3 4
Other						1 2 3 4
In addition to your work history (reverse side), what other experiences, skills or qualifications would especially fit you for work with our company?

EMPLOYMENT HISTORY
Please list all JOBS, beginning with your present or last employer. Account for All periods, including UNEMPLOYMENT, SELF-EMPLOYMENT, AND MILITARY SERVICE. If space is insufficient, list on a separate page.
1. Employer Name & Address	Type of Business		Job Title	Supervisor Name		Telephone Number(s) ( )______-_______ ( )______-_______
Work Performed		Reason for Leaving		Dates Employed From ___/___ To ___/___	Hourly Rate/Salary Start______ End ______		May we contact employer? ____Yes ____No
2. Employer Name & Address	Type of Business		Job Title	Supervisor Name		Telephone Number(s) ( )______-_______ ( )______-_______
Work Performed		Reason for Leaving		Dates Employed From ___/___ To ___/___	Hourly Rate/Salary Start______ End ______		May we contact employer? ____Yes ____No
3. Employer Name & Address	Type of Business		Job Title	Supervisor Name		Telephone Number(s) ( )______-_______ ( )______-_______
Work Performed		Reason for Leaving		Dates Employed From ___/___ To ___/___	Hourly Rate/Salary Start______ End ______		May we contact employer? ____Yes ____No
4. Employer Name & Address	Type of Business		Job Title	Supervisor Name		Telephone Number(s) ( )______-_______ ( )______-_______
Work Performed		Reason for Leaving		Dates Employed From ___/___ To ___/___	Hourly Rate/Salary Start______ End ______		May we contact employer? ____Yes ____No
I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION. I UNDERSTAND THAT MISREPRESENTATION OR OMISSION OF FACTS CALLED FOR IS CAUSE FOR DISMISSAL. FURTHER, I UNDERSTAND AND AGREE THAT MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES AND SALARY, BE TERMINATED AT ANY TIME WITHOUT ANY PREVIOUS NOTICE. “I understand and agree that if I am hired for the position for which I am applying (or for any other position) I shall be a probationary employee for a period of ninety (90) days from the date I actually start work. During such probationary period I may be discharged without notice, for any reason not prohibited by statute, without any claim for additional compensation.” Applicant Signature __________________________________________________________________________ Date ____/____/____
THANK YOU FOR APPLYING